Comprehensive Asthma Checklist

Initial Diagnosis and Confirmation

Establish the diagnosis using spirometry in all patients ≥5 years old to demonstrate reversible airflow obstruction with FEV₁ improvement ≥12% and ≥200 mL after bronchodilator administration. 1, 2

History Documentation

Symptom pattern: Document wheezing, breathlessness, chest tightness, and cough (particularly nocturnal or early morning) 2
Frequency metrics: Record daytime symptoms per week, nighttime awakenings per month, and days with activity limitation 3, 1
Rescue medication use: Quantify short-acting β-agonist use (puffs per day or days per week) 1, 2
Trigger exposures: Identify allergens (dust mite, pets, mold, cockroach), irritants (tobacco smoke, strong odors), exercise, infections, and medications (aspirin/NSAIDs, β-blockers) 1, 2
Exacerbation history: Document number of oral corticosteroid courses, emergency visits, and hospitalizations in past year 3, 2

Physical Examination Findings

Severity indicators: Assess accessory muscle use, ability to speak in full sentences, pulse rate (>120 beats/min suggests severe), pulsus paradoxus, and breath sounds 3, 4
Comorbidities: Examine for rhinitis, sinusitis, nasal polyps, obesity, and signs of GERD 1, 2, 5

Objective Testing

Spirometry (mandatory ≥5 years): Measure FEV₁/FVC ratio and demonstrate reversibility (≥12% and ≥200 mL improvement post-bronchodilator) 3, 2
Peak expiratory flow: Establish personal best value for ongoing monitoring, with >20% variability suggesting asthma 3, 1
Allergy testing: Perform skin or in vitro IgE testing for perennial indoor allergens in all patients with persistent asthma requiring daily medications 3, 1
Bronchoprovocation testing: Consider methacholine or exercise challenge when spirometry is normal but asthma suspected—negative test helps exclude asthma 2

Severity Classification (Treatment-Naïve Patients)

Classify severity before initiating therapy using both impairment and risk domains to determine the appropriate starting treatment step. 3, 1, 2

Intermittent Asthma

Symptoms ≤2 days/week 2
Nighttime awakenings ≤2×/month 2
SABA use ≤2 days/week 2
No interference with activities 2
FEV₁ >80% predicted 2

Mild Persistent Asthma

Symptoms >2 days/week but not daily 2
Nighttime awakenings 3-4×/month 2
Minor activity limitation 2
FEV₁ >80% predicted 2

Moderate Persistent Asthma

Daily symptoms 2
Nighttime awakenings >1×/week but not nightly 2
Some activity limitation 2
FEV₁ 60-80% predicted 2

Severe Persistent Asthma

Symptoms throughout the day 2
Nighttime awakenings often 7×/week 2
Extreme activity limitation 2
FEV₁ <60% predicted 2

Risk assessment: ≥2 exacerbations requiring oral corticosteroids in past year indicates higher risk regardless of impairment level 2

Stepwise Pharmacotherapy Algorithm

Initiate treatment with inhaled corticosteroids (ICS) as the preferred first-line long-term controller therapy for persistent asthma, as ICS improve control more effectively than any other single controller medication. 1, 6

Step 1 (Intermittent)

Preferred: As-needed low-dose ICS-formoterol 1
Alternative: SABA as needed only 2
Pitfall: Outdated SABA monotherapy increases exacerbation risk 1

Step 2 (Mild Persistent)

Preferred: Daily low-dose ICS (200-500 mcg fluticasone equivalent) 1, 2
Alternative: As-needed low-dose ICS-formoterol 1
Evidence: Level A evidence for ICS superiority over all other single controllers 1

Step 3 (Moderate Persistent)

Preferred: Low-dose ICS + LABA combination 3, 1, 2
Alternative: Medium-dose ICS alone 2
Rationale: ICS-LABA demonstrates synergistic effects achieving efficacy equivalent to or better than doubling ICS dose 1
Important: Never use LABA monotherapy without ICS due to rare risk of life-threatening exacerbations 3, 6

Step 4

Preferred: Medium-dose ICS + LABA 2
Consider: Adding long-acting muscarinic antagonist (triple therapy) for improved symptoms and reduced exacerbations 1

Step 5 (Severe Persistent)

Preferred: High-dose ICS + LABA 2
Add-on: Omalizumab for allergic asthma with elevated IgE 2, 6
Add-on: Mepolizumab or reslizumab for eosinophilic phenotype 6

Step 6

High-dose ICS + LABA + oral corticosteroids 2
Before initiating maintenance oral corticosteroids, confirm clinical reversibility with 2-week trial and rule out other pulmonary conditions 3

Control Assessment and Monitoring Schedule

Assess control at every visit using validated tools and adjust therapy accordingly—control assessment drives all treatment decisions after initial classification. 3, 1, 2

Visit Frequency

Every 2-6 weeks: When initiating therapy or stepping up treatment 3, 2
Every 1-6 months: Once control is achieved, depending on treatment step 3, 2
Every 3 months: When considering step-down therapy 3, 2

Control Parameters (≥12 Years)

Well-Controlled:

Symptoms ≤2 days/week 3, 2
Nighttime awakenings ≤2×/month 3, 2
SABA use ≤2 days/week 3, 2
No activity limitation 3, 2
FEV₁ or PEF >80% predicted 3, 2
No exacerbations requiring oral corticosteroids 3, 2

Not Well-Controlled:

Symptoms >2 days/week 3, 2
Nighttime awakenings 1-3×/week 3, 2
SABA use >2 days/week 3, 2
Some activity limitation 3, 2
FEV₁ or PEF 60-80% predicted 3, 2
≥2 exacerbations in past year 3, 2

Very Poorly Controlled:

Symptoms throughout the day 3, 2
Nighttime awakenings ≥4×/week 3, 2
SABA use several times daily 3, 2
Extreme activity limitation 3, 2
FEV₁ or PEF <60% predicted 3, 2

Objective Monitoring

Spirometry: Perform at least every 1-2 years when well-controlled, more frequently if poorly controlled 3, 2
Peak flow monitoring: Consider daily monitoring for moderate-severe persistent asthma, history of severe exacerbations, or poor symptom perception 3, 2
Validated questionnaires: Use Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) at each visit 1

Treatment Adjustment Algorithm

Before stepping up therapy, verify medication adherence, correct inhaler technique, environmental trigger control, and treatment of comorbidities—these are the most common reasons for apparent treatment failure. 3, 2

Step-Up Criteria

Immediate step-up: SABA use >2 days/week (excluding exercise prophylaxis) indicates inadequate control 2
Step up 1-2 steps: If not well-controlled or very poorly controlled after 4-6 weeks of current therapy 2
Warning sign: Increasing SABA use (>2 days/week or >2 nights/month) requires initiating or intensifying anti-inflammatory therapy 1

Step-Down Criteria

Timing: Consider after ≥3 months of well-controlled asthma 2
Monitoring: Schedule visits every 3 months during step-down period 2
Approach: Reduce ICS dose by 25-50% every 3 months if control maintained 3

Before Stepping Up, Check:

Adherence: Review medication-taking behavior and barriers 3, 2
Inhaler technique: Verify and correct at every visit—inadequate technique is a common cause of poor control 3, 1, 2
Environmental triggers: Reassess exposure to identified allergens and irritants 2
Comorbidities: Treat rhinitis, sinusitis, GERD, obstructive sleep apnea, obesity, anxiety, and depression 1, 2

Patient Education and Self-Management

Provide every patient with a written asthma action plan including instructions for daily management, recognizing worsening symptoms, and medication adjustments—this is particularly essential for moderate-severe persistent asthma or history of severe exacerbations. 3, 1, 7

Written Asthma Action Plan Components

Green Zone (80-100% Personal Best PEF) – "Doing Well":

List all daily controller medications with specific doses, frequency, and delivery device 7
Specify quick-relief medication dose and frequency (e.g., albuterol 2 puffs every 4-6 hours as needed) 7
Define symptom criteria: no cough, wheeze, chest tightness, or dyspnea; normal activities; no nighttime awakenings 7
Document numeric peak flow range (e.g., 480-600 L/min) 7

Yellow Zone (50-79% Personal Best PEF) – "Getting Worse":

Identify trigger symptoms: cough, wheeze, chest tightness, dyspnea, nighttime awakenings, reduced activity 7
Provide numeric peak flow range (e.g., 300-479 L/min) 7
Outline medication adjustments: continue rescue inhaler every 4 hours and increase controller dose 7
Instruct to contact provider if no improvement within 24-48 hours 7

Red Zone (<50% Personal Best PEF) – "Medical Alert":

List danger symptoms: severe dyspnea, rescue medication ineffective, inability to perform activities, symptoms persisting >24 hours 7
Record numeric peak flow threshold (e.g., <300 L/min) 7
Emergency actions: immediate rescue dose, oral prednisolone 30-60 mg, call 911 if unable to speak/walk or cyanosis present 3, 7

Inhaler Technique Education

Verify technique at every visit: Inadequate technique is a common cause of poor control 3, 1, 2
Document device type: MDI with spacer, dry-powder inhaler, or nebulizer 7
Use teach-back method: Have patient demonstrate technique to verify comprehension 7

Self-Monitoring Training

Symptom monitoring: Particularly helpful for patients with difficulty perceiving symptoms or history of severe exacerbations 3
Peak flow monitoring: Shows similar benefits to symptom monitoring for most patients 3
Personal best PEF: Establish when asthma is well-controlled for zone calculations 7

Medication Education

Controller vs. rescue: Clearly differentiate daily controller medications (prevent inflammation) from PRN rescue medications (relieve symptoms) 3, 7
ICS importance: Emphasize that ICS must be taken daily even when feeling well 3
SABA overuse: Explain that SABA use >2 days/week indicates need for controller therapy 2

Environmental Control and Trigger Avoidance

Identify specific allergen sensitivities through skin or in vitro testing in all patients with persistent asthma, then implement multifaceted allergen avoidance strategies—single interventions are generally ineffective. 1, 2

Mandatory Interventions

Tobacco smoke: All patients must avoid active and passive tobacco smoke exposure 2
Occupational sensitizers: Identify and eliminate workplace exposures 8

Allergen-Specific Avoidance (Based on Testing)

Dust mite: Encase mattresses/pillows in impermeable covers, wash bedding weekly in hot water, reduce humidity <50% 1
Pet dander: Remove pets from home or at minimum from bedroom, use HEPA filters 1
Cockroach: Professional extermination, seal food in containers, eliminate water sources 1
Mold: Fix water leaks, use dehumidifiers, clean visible mold with bleach solution 1

Other Trigger Management

Medications: Avoid aspirin/NSAIDs in aspirin-sensitive patients, avoid β-blockers 3, 2
GERD: Treat with proton pump inhibitors if symptomatic 1, 2
Exercise: Pre-treat with SABA 15 minutes before exercise 2
Cold air: Use scarf or mask over nose/mouth in cold weather 7

Comorbidity Management

Evaluate and treat conditions that worsen asthma control, as addressing comorbidities provides substantial benefits to asthma outcomes. 3, 1, 2

Rhinitis and Sinusitis

Treat with intranasal corticosteroids 1, 2
Consider allergen immunotherapy when clear relationship between symptoms and specific allergen exposure 2

Gastroesophageal Reflux Disease

Treat symptomatic GERD with proton pump inhibitors 1, 2
Elevate head of bed, avoid late meals 2

Obesity

Encourage weight loss through diet and exercise 1, 2
Obesity increases asthma severity and reduces treatment response 1

Obstructive Sleep Apnea

Screen with sleep study if suspected 2
Treat with CPAP if diagnosed 2

Psychological Factors

Screen for anxiety and depression 1, 2
Provide appropriate treatment or referral 1, 2

Osteoporosis Risk

Consider calcium and vitamin D supplements for patients on chronic ICS or multiple oral corticosteroid courses 3
Consider bone density measurement in high-risk patients 3

Vaccinations

Provide annual influenza vaccination for all patients with persistent asthma 1

Acute Exacerbation Management

Administer high-dose inhaled β-agonists and systemic corticosteroids immediately to all patients with acute severe asthma, as clinical benefits from corticosteroids may not occur for 6-12 hours. 3, 4

Severity Assessment

Severe Exacerbation (<40% Predicted FEV₁ or PEF):

Accessory muscle use, inability to speak in full sentences 3, 4
Pulse >120 beats/min, pulsus paradoxus 3, 4
Decreased breath sounds 3, 4
PEF <40% predicted or personal best 3

Life-Threatening Features:

Normal or high PaCO₂ (5-6 kPa) in breathless patient 3
Severe hypoxia: PaO₂ <8 kPa despite oxygen 3
Low pH or high H+ 3
Exhaustion, confusion, drowsiness, or coma 3

Immediate Treatment

Inhaled β-agonist: Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen, or 10-20 puffs via MDI with spacer 3
Systemic corticosteroids: Prednisolone 30-60 mg PO or hydrocortisone 200 mg IV immediately 3
Oxygen: Maintain SpO₂ >90% 3

Life-Threatening Features Present

Add ipratropium: 0.5 mg nebulized with β-agonist 3
IV bronchodilator: Aminophylline 250 mg over 20 minutes (not if already on oral theophylline) or salbutamol/terbutaline 250 mcg over 10 minutes 3
Magnesium sulfate: Consider for severe exacerbations unresponsive to initial treatment 3

Monitoring and Ongoing Treatment

Measure PEF: 15-30 minutes after starting treatment, then according to response 3
Continue oxygen: Maintain SpO₂ >90% 3
Continue steroids: Prednisolone 30-60 mg daily or hydrocortisone 200 mg every 6 hours 3
Nebulized β-agonist: Every 4 hours if improving, up to every 15 minutes if not improving 3

Hospital Admission Criteria

Life-threatening features present 3
Severe attack features persist after initial treatment 3
PEF 15-30 minutes after nebulization <33% predicted or best 3
Symptoms seen in afternoon/evening rather than morning 3
Recent nocturnal symptoms or worsening symptoms 3
Previous severe attacks, especially rapid onset 3
Concern over patient's assessment of severity or social circumstances 3

Intensive Care Indications

Deteriorating PEF, worsening or persisting hypoxia (PaO₂ <8 kPa) despite 60% oxygen, or hypercapnia (PaCO₂ >6 kPa) 3
Exhaustion, feeble respiration, confusion, or drowsiness 3
Coma or respiratory arrest 3

Unhelpful Treatments to Avoid

Antibiotics: Only if bacterial infection confirmed 3
Sedation: Absolutely contraindicated 3
Chest physiotherapy: Unnecessary and unhelpful 3

Discharge Criteria

PEF ≥70% predicted or personal best 3
Symptoms resolved or minimal 3
Patient able to use inhaler correctly 3
Written asthma action plan provided 3
Follow-up appointment scheduled within 1 week 3
Consider initiating ICS at discharge if not already prescribed 3

Specialist Referral Indications

Refer for consultation or co-management when difficulty achieving or maintaining control, ≥2 oral corticosteroid bursts in past year, or any hospitalization for asthma. 2

Absolute Referral Criteria

Step 4 or higher care required 2
Any hospitalization or ICU admission for asthma 2
≥2 oral corticosteroid courses in past year 2
Difficulty achieving or maintaining control despite appropriate therapy 2

Consider Referral

Immunotherapy or biologic therapy (omalizumab, mepolizumab, reslizumab) being considered 2, 6
Additional diagnostic testing needed (bronchoprovocation, exhaled nitric oxide) 2
Suspected alternative diagnosis (COPD, vocal cord dysfunction, cardiac disease) 2
Occupational asthma suspected 8
Progressive loss of lung function despite treatment 3

Special Population Considerations

Adolescents (12-18 Years)

Involve in development of written asthma action plan and adherence review 3
Encourage taking plan to school, after-school programs, and camp 3
Encourage physical activity with appropriate pre-treatment 3

Older Adults (≥65 Years)

Consider short course of oral corticosteroids to establish reversibility and distinguish from COPD 3
Adjust medications for coexisting conditions and drug interactions 3
Consider increased sensitivity to bronchodilator side effects (tremor, tachycardia) 3
Review technique and adherence—physical or cognitive impairments may affect proper use 3
Consider calcium and vitamin D for osteoporosis prevention 3

Children (5-11 Years)

Monitor growth velocity and height percentile at every visit 3
Consider ophthalmologic examination and bone density measurement with high-dose ICS or multiple oral corticosteroid courses 3
Step-up options not adequately studied in this age group—selection depends on impairment vs. risk domain 3

Documentation Requirements at Each Visit

Every Visit Must Include

Control assessment: Symptoms, nighttime awakenings, activity limitation, SABA use 3, 2
Medication review: Adherence, side effects, concerns 3, 2
Inhaler technique verification: Demonstrate and correct as needed 3, 2
Written action plan review: Update as control changes 3, 7
Trigger exposure assessment: New or ongoing exposures 1, 2
Exacerbation history: Since last visit 3, 2

Periodic Documentation

Spirometry: At least every 1-2 years, more frequently if poorly controlled 3, 2
Allergy testing: At diagnosis for persistent asthma 1, 2
Growth parameters: Height and weight at every visit in children 3
Comorbidity screening: Rhinitis, GERD, OSA, depression annually 1, 2

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